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    Telemedicine: Patient demand, cost containment drive growth

    Joining the trend may not be as expensive or time-consuming as you think, experts say

    Telemedicine has gone mainstream. According to a new report from consulting firm InMedica, a division of IMS Research, 308,000 patients around the world were monitored remotely by providers in 2012 for congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and mental health conditions. (See “World telehealth patients.”)

    And the numbers are expected to skyrocket to 1.8 million in just 4 years, InMedica reports. The growth of technology-assisted care is being driven by containing costs, tracking disease progression, and reducing hospital readmissions, the report says.

    Soon, teleheath will expand from applications that traditionally connected rural areas to specialists and healthcare systems to new applications that streamline care delivery, experts says.

    So, what is telemedicine? It is simply the ability to use telecommunication and technology as a way to provide clinical healthcare, and its applications include everything from video consultation to mobile monitoring devices. Telemedicine includes real-time interactive services, remote monitoring, and “store-and-forward,” which entails capturing medical data and using electronic means to forward that information to other physicians.

    Telehealth applications are proliferating, and primary care will see benefits, experts say. “For primary care physicians [PCPs], it can be a great way to recruit and retain patients,” says Jonathan Linkous, chief executive officer of the American Telemedicine Association (ATA). “Think about how many people wouldn’t go to a bank that doesn’t have an ATM.”

    Nina M. Antoniotti, RN, MBA, PhD, director of teleHealth at Marshfield Clinic in Marshfield, Wisconsin, agrees that telehealth has evolved far from its origins of being something primarily funded by federal grants in rural areas. “It has quickly become part of how we do business,” she says. “It helps people take better care of themselves, and it is not going away.”

    A HEAVILY INTEGRATED PRACTICE

    For Kim Dunn, MD, an internist in Bellaire, Texas, telemedicine is such a big part of her practice that it has become “how we roll.”

    Dunn has been using telemedicine since 1994. The main way she uses it today in her small practice (which includes a nurse practitioner, two staff members, and her) is to create online care plans for her patients that can be accessed by any provider they encounter via a smartphone app. She is able to see any changes recommended by a specialist, for example, and patients can see that their providers are communicating. Patients also are able to send messages to her office via her medical home portal.

    Dunn also uses telemedicine for “curbside consults,” in which specialists are available to answer quick questions that arise during a patient visit.

    “We can send patients to a specialist, which takes time and money, or we can have the patients pay a specialty co-pay, and we get the specialist on the line right then and we discuss the care plan together,” she says.

    Dunn’s practice also is piloting a program for real-time monitoring of patients with chronic diseases. Patients can track things such as their blood pressure or blood glucose levels at home and upload the results as needed. A smartphone app can send them reminders to do it. 

    “Telemedicine is fundamentally about communication, and that’s how we use it,” Dunn says.

    She is so passionate about using technology to improve quality in healthcare that she started the Your Doctor Program, which features the aforementioned medical home portal. Dunn says a key element of her portal is the ability to create and modify care plans, as opposed to most electronic health record (EHR) systems, which merely document the care that a physician has provided.

    “That lets the doctors get paid,” she says. “Well, big whoop; who cares? It’s just a document service. We need a new model of care. My goal is to get rid of the ‘tele’ in ‘telemedicine,’ and just make it ‘medicine,’ ” Dunn continues. “Getting rid of the silos in healthcare requires communication, and that is what telemedicine can deliver.”

    USES SPREADING

    When it comes to telemedicine services, radiology was the top driver, with 5 million patients having a diagnostic test read by an off-site specialist, according to the ATA. Another 1 million patients had implantable pace makers or other devices monitored remotely, and about 400,000 patients received mental health services via telemedicine. Also, he says, about 10% of all intensive care beds are linked to an intensivist who is off-site.

    “Telemedicine is happening everywhere, regardless of geography,” he says. “It is integrated into and transforms the normal practice of care.”

    Heavy patient involvement is a cornerstone of telemedicine today, he adds, especially with smartphone technology and remote monitoring. “It is no longer just a physician communicating with a hospital,” he says.

    Mario Gutierrez, executive director of the Center for Connected Health Policy, says that although video consults are still abundant, “store and forward” technology is growing rapidly as well. Such technology allows a patient to take a photo of a problem, such as a healing wound, and send it to his or her physician to review.

    “This greatly increases a [PCP’s] efficiency,” Gutierrez says.

    VALUE TO THE SYSTEM

    Not all telemedicine is the same, Linkous stresses, but it almost always leads to efficiencies and savings in an already-overburdened system that faces increasing doctor shortages in the future.

    “There will be a huge need to share specialists, and telemedicine is clearly the way to do it,” he says. “There is no need for so many physicians to travel from site to site.”

    One of the biggest potentials for telemedicine to reduce costs, Linkous believes, is the use of remote monitoring to keep patients with chronic conditions out of the hospital and reduce their use of emergency departments.

    “Having them send in their vital signs for assessment on a regular basis is much more efficient than waiting until they call to say something is wrong,” he says.

    Antoniotti notes that systemic cost savings are further achieved through coordination of treatment plans, which increases patient adherence, and through decreasing the length of time that lapses between referral to a specialist and appointment. Gutierrez believes the efficiencies that can be achieved through telemedicine will be essential to smaller private practices as they navigate upcoming healthcare reforms.

    “We are rapidly becoming a country that is integrating technology in all of its forms into mainstream care,” he says. “The physicians and group practices that will survive reform are those that embrace the value of technology and incorporate it into their practice.”

    COSTS

    Many physicians worry about the cost of adopting telemedicine in their practices. For Dunn, the start-up costs have been minimal. She simply uses video cameras that are embedded into office computers when teleconferencing with specialists.

    “It just needs to be reliable and [Health Information Portability and

    Accountability Act]-compliant,” not expensive, she says.

    Antoniotti says small practices can acquire basic video equipment, an electronic stethoscope and otoscope, a document camera, and a handheld patient camera for $10,000 or less.

     “Most practices can see a return on their investment in about 3 months,” she adds.

    Gutierrez agrees that investments in telehealth will pay for themselves quickly, particularly as healthcare reform rewards PCPs for keeping overall costs of patient care down.

    “It is part of moving toward a system based on value and quality,” he says.

    REIMBURSEMENT

    Of course, any expenditures need to be weighed against potential income. The good news is that 42 states now offer some form of Medicaid reimbursement for telehealth services, according to the National Conference of State Legislatures, and 16 states now require private insurers to reimburse completely for telemedicine services. (See “Reimbursement for telehealth services.”)

    Similar legislation is being considered in Washington, DC, Connecticut, Florida, Indiana, Mississippi, and New Mexico, according to the ATA.“Reimbursement is definitely getting better,” Linkous says. “In fact, many insurers are starting to realize the value of telemedicine in reducing costs and making patients happy, so some are complying willingly.”

    Gutierrez emphasizes that no two states have the same language about or understanding of what telemedicine is, however, so you need to study your situation. “The field has evolved dramatically, and many different ideas exist,” he says.

    Antoniotti says that Marshfield Clinic has about 800 physicians in primary care and 45 clinical specialties who see patients at 75 sites of all sizes. About half of those sites are telemedicine-enabled. They use telemedicine to reach patients in many settings, including skilled nursing facilities.

    “We get great reimbursement because we are a multispecialty practice in a rural area setting seeing a variety of patients,” she says.

    Like Gutierrez, she advises providers considering getting into telehealth to consider their mix of payers; Medicare, Medicaid, and private payers all have different guidelines. “Look at what applies to your practice and your area,” she says.

    Beyond direct reimbursement, though, she encourages providers to view telemedicine as a way to stop patients from drifting away from their practice.

    “By bringing specialists to them, we keep patients in our facility, keeping the revenue here without the cost of actually having a specialist on-site” and reducing the risk the patient never returns, she says.

    An added bonus is that PCPs who sit in on tele-consults with specialists build more expertise and skill, which helps them offer more value to future patients, she says.

    PITFALLS TO AVOID

    Gutierrez advises physicians to avoid a few pitfalls as they integrate telehealth. First, older technology may not blend well with newer options. As an example, if an EHR does not share information with outside providers, then patient records may need to be faxed before a video consult.

    Also, be sure patient confidentiality is protected, he says. A traditional email system is not enough, and use caution when personal devices, such as an iPad, are employed.

    “Some facilities issue their own devices [with adequate security installed] for just this reason,” Gutierrez says.

    Also, remember that although many legitimate telehealth vendors exist, some illegitimate ones do as well. “Do careful research, and assess the quality and cost being offered before making any decisions,” he says.


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    Becoming a provider

    In addition to updating their practices, primary care physicians have another option to participate in telemedicine: becoming a provider for a telehealth network.

    One example is Teladoc, a company that offers its members 24/7 access to a physician via phone or online video consultations.

    According to the company, all the doctors in its national network are U.S. board-certified family physicians, internists, and pediatricians who use electronic health records to diagnose and treat conditions as well as write prescriptions, when necessary.

    Jason Gorevic, chief executive officer of Teladoc, says that doctors who participate as providers do consults when they want, on their own schedules. “Some make thousands of dollars a month in supplemental income while increasing their geographic reach,” he says.

    The company also can provide physicians with the technology to reach their own patients remotely and hand off after-hours calls to other Teladoc providers as it suits their schedules

    “They can avoid being on call at all times, but they can always choose to accept calls from their own patients to keep that revenue there,” Gorevic says.  

    He says patients enjoy having anytime access to a physician and reports a 97% satisfaction rate. Patients particularly appreciate being able to get treatment without sitting in a physician’s waiting room with potentially contagious people, especially with this year’s heightened flu outbreak, Gorevic adds.

    Although most of Teladoc’s 5 million members are enrolled as a benefit of being part of a large employer or other health plan, he believes patients increasingly are willing to pay out of pocket for such services. Gorevic says most patients who visit an emergency department (ED) say they only did so because they did not have access to care elsewhere when they needed it.

    Paying for a telemedicine service to avoid spending hundreds or even thousands of dollars on an ED visit is worth it to many of them, he concludes.


    How to get started

    Medical Economics asked several telemedicine experts what advice they would give to primary care physicians in private practice who are interested in expanding into telehealth. Some highlights of their answers:

    Kim Dunn, MD, in private practice in Bellaire, Texas: The biggest obstacles are not related to cost, she says. They are related to staff training, reimbursement, patient permissions, liability issues, and forging relationships with specialists. She suggests using online training programs as a first step to get started.

    Jonathan Linkous, chief executive officer (CEO) of the American Telemedicine Association: Start small. Do not jump in and invest in a huge broadcast studio with a staff of engineers. Your first foray into telemedicine can be as simple as putting in a protocol to send and receive photos from patients, he says. For example, photographs of postoperative wounds can be sent via smartphone, allowing a physician to monitor healing without the patient coming in. Combine this effort with an Internet portal that allows patients to make appointments, pre-pay copays, and see laboratory test results, he advises. “Get over your fear, and know that these things will make you more efficient and will make patients happier,” he says.

    Nina M. Antoniotti, RN, MBA, PhD, director of telehealth at the Marshfield Clinic in Marshfield, Wisconsin: First, analyze the healthcare needs in your patient population that can be met with telehealth. Then find someone who does telehealth well, and ask him or her to help you, she advises.

    Mario Gutierrez, executive director of the Center for Connected Health Policy: Make use of the resources offered by the Telehealth Resource Centers funded by the U.S. Department of Health and Human Services’ Health Resources and Services Administration Office for the Advancement of Telehealth. Nationally, 12 regional centers and two national centers focus on technology assessment and telehealth policy. To find the one that serves your state, visit www.telehealthresourcecenter.org.

    Jason Gorevic, CEO of Teladoc: Make sure you get a telehealth system that is truly a system, not just a patchwork of Skype and email. Look for a secure, Health Information Portability and Accountability Act-compliant system that is designed for clinical interactions.


    Reimbursement for telehealth services

    Forty-two states now offer some form of Medicaid reimbursement for telehealth services, and 16 states mandate that private payers cover what the states deem as telehealth services (definitions can vary by state) when they are medically necessary and otherwise would be covered if they were provided in a face-to-face office visit. Reimbursement rates for telehealth services may not match those related to face-to-face services. Before providing or billing any telehealth services, check with individual payers to determine whether they reimburse for such services and, if so, which services and how much.

    For more information about various states’ requirements, see the National Conference of State Legislatures Web site at www.ncsl.org/issues-research/health/state-coverage-for-telehealth-services.aspx.